23 April 2011

This wound poses some interesting management issues. As you can see, it's a fairly clean amputation just beyond the distal interphalangeal (DIP) joint. The patient, optimistically, brought in the amputated portion nicely iced, but reimplantation at this level is not feasible. The blood vessels there are too small and distorted to anastomose. Such a relatively long section to re-install requires good blood flow or it will simply necrose and fall off. So I had to disappoint the patient and tell him it could not be made whole again.

However, the technical issue is that with this very clean amputation there was not enough soft tissue left to close around the stump. Ordinarily, I would take a bone rongeur to nibble away at the residual bony stump until there was enough slack in the skin to pull it across the stump and close it. But this guy had just a bit of intact distal phalanx. I would have had to remove the entire thing, which is not preferable since the flexor and extensor attachment points were still intact. Taking out the rest of the bone would have made the finger weaker and less mobile.

So, in the McGyver-like fashion that ER docs must emulate, I improvised. I took the devitalized fingertip and started harvesting. I excised the bone and the nailbed, leaving only the finger pad and a generous fat pad underneath. I thinnned the fat pad a bit, and trimmed the skin to fit the stump, then tacked it on like a cap. It looked pretty good, and I am optimistic that my little graft will survive. If it does, the fact that I left a fat pad will give him a little cushion over the bone and a relatively functional finger.

But still, the principle remains. Fingers and spinning blades of any sort should not mix.

9 comments:

Neat case! Thanks for revisiting the anatomy and the complexity of your decision making. As someone entering urology, I don't often thing about the flexor and extensor tendons connecting into the DIP. Always good to revisit!

I think the worst one I saw was finger vs. chipper/shredder. Finger vs. tiger was a close second (and not this patient's first amputation from aforementioned animal) He had a sense of humor though. I suggested he find a new line of work, and he held up his mangled hand and said he had considered being a surgeon, but it was a little late at this point.

Few years ago one of the young teens in our circle was horsing around on a riding mower and lost some toes when his foot went under the deck. In general I don't think most people think of lawn mowers as dangerous, but I sure do.

Under what circumstances would one reach into the moving blades of a lawnmower? I'll admit that I'm not the sharpest knife in God's drawer, but I think I'd probably be able to figure out that it's not the best thing to do.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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